Insurance games

We all have our pet peeves about problems we have had with insurance companies from the patient's side of things. But I wanted to give you an idea of some of things we have to deal with from the doctor's side of things. Why should you care? Because when insurance companies cause problems with doctors it often translates into problems for patients.

A recent example from my own practice is that I recent performed a pediatric neuropsychological evaluation. Before all evaluations, my outpatient administrative coordinator calls the insurance companies to get pre-authorization for the service, which is rather expensive. We want to know if the insurance company will pay because if they do not then the patient has to sign a self-pay form. The patient wants to know if the service is pre-authorized because then they have a sense of what they will be responsible for.

So in the case I described above, we were informed by the insurance company that the evaluation would be authorized and paid in full. So several months go by after the evaluation and no payment. Why? Because now the insurance company is demanding a letter of support from the child's school saying that such an evaluation was necessary and that the service could not be provided in the school to begin with.

It's not the reasoning that bothers me because obviously the insurance company does not want to pay for a service that is not needed or that can be done elsewhere for free. What bothers me is the procedure. If the insurance company wanted this information, they should have asked for it before the evaluation was done instead of afterwards. Now the patient's family is upset because they think they may be saddled with a bill they cannot pay out of pocket.

When my office called the insurance company back we were told that the insurance company has the right to ask for anything they want after the fact. Well, ok then. But guess what that means now? Now when we get a referral in which the patient has this insurance, we will not schedule an appointment until we get this type of letter, regardless if they ask for it. This delays care to the patient. What many people eventually do is refuse to see patients from certain insurance companies that play this type of shell game. This only further limits the choices of the patient and is an example of how problems behind the scenes affect patient care.